Approved drugs for athletes. Which Russian drugs are prohibited on the Vada list? Overview of the main changes with explanations

The World Anti-Doping Agency (WADA) lists hundreds of banned drugs and thousands of related substances. Thus, the rules cover even those drugs that have not yet been invented. Most drugs fall into 9 broad categories, which are detailed in The Washington Post.

1. Steroids for muscle building

In almost every sport, athletes are most often caught using anabolic steroids. Weightlifters, swimmers and sprinters use them to build muscle, increase strength and burn fat, while football players and cyclists use them to speed up muscle recovery after training.

Long-term use of steroids threatens serious health consequences: baldness, acne, gynecomastia in men, heart attacks and even cancer.

2. Exciting stimulants

Amphetamine and similar stimulants improve reaction time, reduce drowsiness, increase blood flow to muscles, and induce euphoria or aggression. They can also improve endurance and muscle strength. However, these drugs increase heart rate and interfere with thermoregulation. Several cyclists have died during racing due to stimulant use, myocardial infarction and subarachnoid hemorrhage. Also, taking amphetamine causes anxiety, insomnia, panic and psychosis.

The use of stimulants is only prohibited during competition. Apart from cycling, they are most often used in swimming, running, football and rugby.

3. Hormones

The most popular hormone among athletes is erythropoietin (EPO), which helps the blood carry more oxygen and increases muscle endurance. In 2012, famous cyclist Lance Armstrong was caught using this drug, for which he was disqualified for life and deprived of all titles.

Another popular doping agent is growth hormone, which athletes use as a tougher alternative to steroids.

The list of prohibited drugs also includes insulin and some fertility drugs: they help increase muscle mass and are often taken in combination with anabolic steroids.

Lance Armstrong is the only athlete to finish first overall in the Tour de France 7 times. In 2012, he was banned for life for doping and stripped of all sports titles.

4. “Masking” drugs

Diuretics (diuretics) help wrestlers quickly lose extra pounds while remaining in the required weight category. They can also dilute the concentration of other drugs in your urine, helping you pass a drug test. Drugs called plasma expanders do the same thing with blood.

When considering the problem of doping in modern sports, one cannot ignore one extremely important issue, both medically, legally and morally. This is the problem of using drugs classified as doping by WADA for therapeutic purposes.

First of all, it should be borne in mind that all substances included in the WADA list of prohibited substances can be divided into two groups:

• substances that are medicines or components of medicines in different countries - this is the majority of prohibited substances;
• substances that do not have the legal status of medicines.

Of course, substances belonging to the second group cannot under any circumstances be used as medicines, not only in sports medicine, but in general in medical practice in any civilized country. Examples include, for example, a number of anabolic steroids that are legally drugs of veterinary medicine (Finaject, Finaplix, Check Drops) or designer steroids (the notorious tetrahydrogestrinone), testosterone metabolite epitestosterone, synthetic anabolic zeranol (banned even in animal husbandry and therefore used illegal in this area), a number of substances very different in chemical structure and biological activity classified as “stimulants” (amphepramone, amifenazole, amphetaminil, benzphetamine, dimethylamphetamine, ethylamphetamine, heptaminol, isometheptene, levmethamphetamine, D-methamphetamine, methylenedioxyamphetamine, methylenedioxymethamphetamine, p-methylamphetamine, parahydroxyamphetamine, pemoline, tuaminoheptane, etc.), a number of narcotic analgesics excluded from all Pharmacopoeias (heroin, beta-hydroxy-3-methylfentanyl, desomorphine, etorphine, thiofentanyl, etc.) and some other substances.

However, the majority of prohibited substances should be classified in the first group - that is, completely legal pharmacological drugs officially used in medicine for the treatment, prevention and diagnosis of diseases in humans. Indications for the clinical use of a particular drug are clearly specified in the Instructions approved by the authorized body of the state that has authorized its use on its territory. At the same time, some of the drugs classified as prohibited by WADA are used, in accordance with the approved Instructions, in urgent, i.e., emergency situations, for life-saving reasons. Examples include the use of narcotic analgesics for persistent pain associated with injuries or myocardial infarction, for indomitable (life-threatening) cough, for severe shortness of breath (heart failure), for pulmonary edema, i.e. in cases where non-narcotic analgesics are ineffective. Glucocorticoid drugs are widely used for acute hormonal insufficiency of the adrenal cortex, hemolytic anemia, glomerulonephritis, acute pancreatitis, hepatitis; In connection with the anti-shock effect, glucocorticoids are prescribed for the prevention and treatment of shock (post-traumatic, surgical, toxic, anaphylactic, burn, cardiogenic, etc.). Among the indications for the use of adrenergic drugs in clinical practice, there are also emergency conditions, in particular, acute hypotension of various origins (collapse, shock, overdose of ganglion blockers, poisoning with inhibition of the vasomotor center, intoxication), cardiac arrest, hypoglycemic coma, bronchial asthma, anaphylactic shock , allergic swelling and other allergic reactions. As for β-blockers, they were created (and are now used) as a means of treating coronary heart disease (angina pectoris, myocardial infarction), tachyarrhythmia, and complex treatment of hypertension.

Athletes, like all people, may need treatment that requires medications. If substances needed for treatment are doping and are prohibited under anti-doping rules, the athlete may still be allowed to use them. This procedure is called therapeutic use case (TUE). For TUE, a separate permit must be obtained in each specific case.

A TUE may be granted if:

• the athlete is at risk of serious deterioration in health without taking any prohibited drug;
• the therapeutic use of a prohibited drug will not significantly improve performance in competition;
• There is no alternative to the use of this drug or method (among those approved).

WADA has developed an International Standard for Therapeutic Uses of Prohibited Substances. Under this standard, all International Federations and National Anti-Doping Agencies are required to accept a TUE request from an athlete in need of treatment. In Ukraine, the request is considered by the relevant sports federation or the Therapeutic Use Exemption Committee (TUC), which consists of independent medical experts.

The procedure for submitting a TUE request is as follows.

An international athlete or international competitor must submit a TUE request to the international federation for his or her sport. This can be done through the Ukrainian federation. Other athletes (not competing in international competitions) must submit a request to the TEC. Athletes should not submit a TUE request to more than one organization. Athletes cannot submit a request directly to WADA.

During major international competitions, special therapeutic use protocols may come into force. Therefore, participants in such competitions should check with their sports federation or TUEC to determine if there are any changes to the standard protocol for therapeutic use during upcoming competitions.

At the same time, during the validity of the TUE permit, the TUE may at any time initiate a review of the decision to issue the permit.

WADA, through the Therapeutic Use Exemption Committee, has the right to review any TUE issued by a federation or TUE and accordingly revoke any decision. In addition, athletes who have submitted a TUE request to a federation and have been denied it may refer the decision to the WADA Therapeutic Use Exemption Committee. If WADA determines that the denial of a TUE was not in accordance with the international standard, the Agency may overrule the decision of the federation or anti-doping organization.

If WADA rejects the decision to grant a TUE, the athlete or his representatives may appeal to the International Arbitration for Sport in Lausanne for a final decision.

In practice, the procedure for applying for a TUE is as follows. The athlete must:

• Contact your sports federation (or the TUE directly) and obtain a TUE application form.
• send the form filled out by the doctor, with your signature and with the necessary documents attached, to the international federation and the TEC.

It is important to remember that a TUE request must be submitted at least 21 days before the start of the competition. It is important to attach medical examination data, an extract from a medical card or medical history to the application. The request must be completed in block letters. Previously, there were two forms of requests: shortened (for beta-2 adrenergic agonists and glucocorticosteroids) and full. In accordance with the 2009 International Standard for Therapeutic Use Exemptions, the abbreviated form has been removed and a declaration of use must be submitted through ADAMS when using corticosteroids by intra-articular, periarticular, intraligamentous, epidural, intradermal, or inhaled injections. If glucocorticosteroids are administered orally, rectally, intravenously, or intramuscularly, a request must be submitted along with all relevant documentation as noted above. Topically applied glucocorticosteroid preparations (applied to the skin, including iontophoresis and phonophoresis, as well as drops in the ears, nose and eyes) are not prohibited, and their use does not require a declaration of use. The use of beta-2-agonists requires TUE approval.

The athlete may begin treatment only after receiving written permission from the relevant organization (except in cases where urgent medical intervention is required for an acute condition, in which case retrospective consideration of the application is allowed). Examples of this kind of urgent and, moreover, fairly typical conditions for athletes include traumatic shock or sunstroke.

As is known, injuries of varying localization and severity are typical for various sports. Severe injuries are naturally accompanied by the development of traumatic shock - a severe pathological process that develops in response to injury and affects almost all body systems, primarily the circulatory system. The pathogenesis of shock is based on: hemodynamic factor (reduction in the volume of circulating blood as a result of its leakage from the vascular bed and deposition), anemic factor, pain and violation of the integrity of bone formations. Prevention and treatment of traumatic shock is a very complex set of therapeutic measures, depending largely on the degree of shock, but in any case providing for the emergency use of local anesthetics, narcotic analgesics and glucocorticoids (all together or selectively depending on the specific clinical situation). Another example of an urgent condition typical for sports practice, requiring the use of prohibited drugs (diuretics, most often furosemide), can be sunstroke, accompanied by pulmonary edema; Moreover, refusal to use diuretics often poses a threat to the patient’s life.

If a prohibited substance was used during the provision of emergency medical care, the situation is considered as follows. The International Standard for Therapeutic Use Exemptions allows prohibited substances to be used for treatment before they have been approved for use. Also, in addition to this situation, the use of prohibited substances is allowed until permission is received in the event that the athlete, due to exceptional circumstances, does not have sufficient time or opportunity to submit a request, and the TUEC considers the request, as well as in cases where the athlete does not use international level (or not competing at an international sporting event, if specified by the international federation) of formoterol, salbutamol, salmeterol and terbutaline inhaled for the purpose of treatment.

The therapeutic use permit specifies the dosage, frequency and method of use of a specific drug, which the athlete must strictly follow. If it is necessary to change the method, frequency of use or dosage, a new request must be submitted. The athlete must strictly comply with the requirements specified in the TUE permit. Information regarding a TUE issued by an international federation or TUE is sent to WADA, which may review the decision if it does not comply with the international TUE standard.

The request and documents are reviewed within 30 days, so the athlete must send these materials to the anti-doping organization 30 days before the moment when he requires permission.

To summarize, it should be noted that in general the entire procedure is cumbersome and has a pronounced element of subjectivity. Firstly, this element is present in the definition of the diagnosis - you can always, if desired, refer to the fact that the results of any laboratory or instrumental method are missing, which allows us to consider the diagnosis to be finally established and confirmed. Secondly, the question of the effectiveness and appropriateness of using certain drugs for the treatment of a specific pathology and in a specific patient is debatable; however, common sense suggests that a doctor standing at the bedside of a particular patient can more correctly determine these issues than some “members of the Clinical Institute”: even if they are qualified specialists in the field of sports medicine, they have not observed the patient with this clinical condition case are known only in absentia, and, in addition, it is possible that they may have no experience at all in treating this particular pathology. In other words, obtaining a TUE permit largely depends on the subjective factor. This equally applies to applying for a TUE retroactively for emergency reasons - saving a person’s life can be qualified as doping, with all the ensuing consequences for both the doctor and the athlete.

All this contradicts both common sense and moral principles, as well as legal norms regulating the activities of medical workers. The approach according to which a doctor who saved a person’s life can be accused of any unacceptable actions looks completely absurd and immoral! Moreover, a doctor who did not do everything possible to save the life of his patient is an oathbreaker, because before starting his medical career he took the Hippocratic oath! As for the legal aspects, failure to provide medical care by a medical professional is an illegal act in any civilized country. For example, legislative acts of Ukraine recognize the life and health of a person as the object of a crime, and also determine the procedure for medical and pharmaceutical workers to perform their professional duties.

According to the current legislation of Ukraine, in his professional activities, a medical practitioner bears administrative and criminal liability for violating the provisions of the “Fundamentals of Ukrainian Legislation on Health Protection”. The types of doctor's responsibility and the subjects around which the doctor's liability relationship arises can be presented as follows:

The above “Fundamentals...” provide, in particular, for liability for failure to provide medical care (Article 39) and violation of the conditions of medical intervention (Articles 42-43). These articles are duplicated in the Criminal Code of Ukraine: Art. 136 - failure to provide assistance to a person who is in a life-threatening condition; Art. 137 - improper performance of duties regarding the protection of the life and health of children; Art. 139 - failure to provide assistance to a patient by a medical worker; Art. 140 - improper performance of professional duties by a medical or pharmaceutical worker. Liability under these articles actually occurs as determined by the court in accordance with the articles of the Criminal Code of Ukraine. Of course, similar articles are present in the criminal legislation of any other civilized country.

However, even in cases where the therapeutic use of a doping drug is not urgent, the officially determined period for consideration of the application (30 days) is not always acceptable from the point of view of the treatment process and common sense.

The World Anti-Doping Agency WADA has released a new list of prohibited substances and procedures, which came into effect on January 1, 2016.

The list of drugs and procedures prohibited in sports can be found in the accompanying documents on the right side of the page. Following this list is the responsibility of each organization that has signed the Anti-Doping Code.

The 2016 list contains some changes compared to the edition a year ago. Particular attention should be paid to the following points:

In the category "S2. Peptide hormones, growth factors, similar substances and mimetics", leuprorelin replaced triptorelin as a more universal example of a drug that affects the production of human chorionic gonadotropin and luteinizing hormones.

In the category "S4. Hormonal and metabolic modulators", all insulin mimetics have been added to the list to cover the full spectrum of insulin receptor agonists. In addition, meldonium (Mildronate) was added to this category, since there have been cases of athletes taking this drug to improve performance.

Intravenous infusions and injections
UEFA reminds about the status of intravenous infusions. In accordance with the 2016 WADA Prohibited Substances List (Category "M2. Chemical and Physical Manipulation"), all intravenous infusions and/or injections exceeding 50 ml over a 6-hour period are prohibited, both in-competition and out-of-competition. Exceptions include cases of hospitalization, surgical procedures or clinical trials, or when the player has received an appropriate Therapeutic Use Exemption (TUE).

Intravenous infusions were included in WADA's list because they may be used to increase plasma volume, mask the use of prohibited substances, or misrepresent the athlete's biological passport.

The use of intravenous infusions in various sports has been documented, including dietary supplements and vitamin cocktails given to athletes to recover from injuries and stress. This practice is prohibited in all cases other than prior receipt of a TUE. It should also be noted that the use of intravenous fluids to replace fluid loss after exercise in mild to moderate dehydration is not clinically indicated or supported by the medical literature. There is ample scientific evidence that oral rehydration is the best recovery method.

Anyone who uses intravenous injections without a medical reason is violating anti-doping rules, regardless of whether the drug is prohibited or not. In such cases, sanctions can be applied both to the player himself and to the person under whose supervision the procedure was carried out.

Additional Information
More detailed information on the list of prohibited substances, intravenous infusions, and therapeutic use exemptions (TUE) is contained in the circular letter that was sent to all national associations and clubs currently participating in European competition in December 2015. The letter is also available in the documents section of this page.

Timofey Gennadievich Sobolevsky, Deputy Director, Head of the Laboratory of Chromato-Mass Spectrometric Analysis Methods of the Federal State Unitary Enterprise Anti-Doping Center, Candidate of Chemical Sciences, talks about the difficult task that analytical chemists face during sports competitions.

A huge number of anti-doping tests are done around the world, not only during competitions, but also between them. What samples are taken from athletes and what problems do chemists face?

Our FSUE Anti-Doping Center analyzes about 15,000 urine samples and about 4,000 blood samples per year. Most of the substances on the list of prohibited drugs are determined in urine samples. However, over the past ten years, blood tests have been increasingly taken, since this is the only way to check whether the athlete has had a blood transfusion, as well as determine the hemoglobin level, hematocrit, red blood cell concentration and other parameters that the Athlete’s Biological Passport program assumes.

Growth hormone, some types of erythropoietin and insulins are also determined exclusively in blood serum. Today, some anti-doping laboratories are conducting studies to demonstrate that blood testing can be comprehensive and can determine everything. But since it is still more difficult to collect blood (sampling requires a specialist with a medical education), and many techniques will have to be developed anew, anti-doping control will probably continue to be mainly based on the analysis of urine samples.

Chemists working in the field of doping control have quite a lot of problems. Over the past ten years, the list of prohibited drugs has expanded significantly, new prohibited classes of compounds have appeared, for the determination of which it was necessary to develop and implement analytical methods. It is clear that this requires money and extremely highly qualified laboratory personnel.

In general, the system works as follows:

There are anti-doping laboratories that analyze samples received by them, and there are national and international anti-doping organizations that plan and collect these samples from athletes, both during and outside of competition. So that doping control inspectors can take a sample at any time, international athletes provide information about their whereabouts several months in advance (for every day!). The list of substances prohibited out of competition is almost half as long, but in general doping control occurs almost continuously. The laboratory's analysis results are sent to anti-doping organizations, which draw appropriate conclusions and investigate violations. The laboratory only detects the presence (or absence) of prohibited substances in athletes’ samples and does not provide feedback to athletes.

How is it possible to identify such a large number of diverse substances? And what new methods do chemists offer for this?

It's really not easy. About ten years ago, when the list of prohibited substances was approximately half as long, most anti-doping laboratories followed the practice of having a separate line of analysis for each class of substance. In other words, volatile stimulants, narcotics, anabolic steroids, diuretics, beta blockers, corticosteroids were separately determined... Due to the large number of lines of analysis, it was impossible to quickly examine many samples. To “catch” small concentrations of substances, samples had to be concentrated. Most laboratories combined gas chromatography with mass spectrometry. To determine substances in nanoquantities, high-resolution mass spectrometers (magnetic sector analyzers) were used, and this is complex and difficult-to-use equipment.

At some point, the laboratories were simply overwhelmed, as anti-doping services, trying to test as many athletes as possible, sent more and more samples.
Today, laboratories use systems that combine high efficiency chromatographic separation (gas and liquid chromatography) and mass spectrometric detection. These are the so-called triple quadrupole mass analyzers. New instruments determine with the highest sensitivity and reliability whether the sample contains the substances of interest to us. Firstly, this allows you to use a smaller sample volume (to the point that it can be diluted several times with water and directly introduced into the device, if we are talking about liquid chromatography), and secondly, it increases the number of compounds determined in one analysis . Thus, thanks to modern equipment, methods have become simpler and more universal, and this has significantly increased the productivity of anti-doping laboratories.

At the same time, sample preparation methods were developed. If previously liquid-liquid extraction was mainly used, which is almost impossible to automate, now solid-phase extraction is increasingly used, including an option in which a sorbent with the desired properties is applied to the surface of magnetic microparticles. It is very convenient to manipulate such particles - the suspension is added to the test sample, and the compounds being determined are themselves adsorbed on their surface. The tube is then placed in a magnetic field, which fixes the particles at the bottom, and the remaining sample is poured out. After this, the microparticles are usually washed to remove unwanted components, and the desired compounds are washed off with a small volume of organic solvent - and that's it, the sample is ready for analysis.

The sample preparation procedure is not only simple, but can be easily automated. This is a kind of nanotechnology in chemical analysis, and is usually used to search for substances of a peptide nature, such as synthetic analogues of insulin, in urine or blood. Now chemists are finding out whether this method can also be used to extract low molecular weight compounds. Unfortunately, the method is quite expensive, so it is not always used in all laboratories.

In general, anti-doping control is focused on identifying specified compounds. During the analysis, you will see only those prohibited drugs for which your gas chromatography-mass spectrometer is pre-set, and all other information about the sample is lost. At the same time, the list of prohibited substances in many sections contains the following wording: “... and other substances with a similar structure or properties” or in general “any substances that are at the stage of clinical trials and not approved for official use.” To be able to analyze the sample again for some other substances without repeating sample preparation, you need to use instrumental methods that save all information about the sample. There are such devices: these are time-of-flight mass spectrometers or mass spectrometers operating on the principle of an orbital ion trap. They record all data (not just given data) with high resolution, but working with such devices also has its own difficulties and limitations. Despite their high cost, they have already become part of laboratory practice - for example, we have several orbital ion traps in Moscow (they are called “Orbitrap”).

How quickly is one analysis done? Why is an athlete sometimes disqualified after he has already received a medal?

According to the international standard, 10 working days are allotted for analysis. At major sporting events, such as the Olympic Games, this period is 24 hours for samples that show a negative result, 48 hours for samples that require additional testing (i.e. where the screening result shows the presence of a prohibited substance), and 72 hours for complex tests - such as the determination of erythropoietin or the origin of testosterone by isotope mass spectrometry.
However, in recent years, the practice of long-term (up to eight years) storage of samples has emerged so that in the future, as new prohibited drugs and methods for their determination become available, it will be possible to carry out repeated analysis. This was the case, in particular, with samples from the 2008 Olympics: more than a year after the end, they were analyzed for the new generation erythropoietin MIRCERA in the Lausanne anti-doping laboratory, and the result for some athletes was disappointing.

When did they start testing athletes for the use of prohibited drugs? How many are on the list for the Olympics this year?

The International Olympic Committee (IOC) published the first list of prohibited drugs in 1963, but testing began only five years later (in 1968) - at the Winter Olympic Games in Grenoble and the Summer Olympics in Mexico City. Actually, the history of anti-doping control began from the moment when it became technically possible to do such analyzes en masse thanks to the active development of chromatography and mass spectrometry methods.

At first, the list of prohibited drugs included only stimulants, narcotic analgesics and anabolic steroids. Over time, other classes of compounds were added - diuretics, beta-blockers, beta2-agonists, drugs with anti-estrogenic activity, peptide hormones, and the number of drugs within each class increased markedly.

Currently, the list of prohibited drugs, which is reviewed once a year, contains about 200 compounds of various natures. It should be noted that a significant part of them (for example, almost all anabolic steroids) are completely metabolized (modified) when they enter the human body, so laboratories often determine not the prohibited drugs themselves, but the products of their transformation in the body. This is a rather difficult task - in order to solve it, you must first study the metabolic process in detail, and then learn to identify the longest-lived metabolites. In fact, modern anti-doping analysis is at the intersection of analytical chemistry, biochemistry and pharmacology.

The preparation of the anti-doping laboratory for the Olympic Games begins long before them. After all, by the right time, she should already have all available methods and techniques, including those that have not yet entered into everyday practice.
There don’t seem to be many laboratories in the world officially accredited by the IOC, the results of which are recognized by the IOC. But at the same time, there are probably other laboratories in every country that monitor their athletes and, undoubtedly, can warn them if they detect any prohibited substances.

Nevertheless, scandals do happen. What is the problem? In athletes or in the level of qualifications and equipment of accredited laboratories that determine lower concentrations and a wider range of substances?

Only laboratories accredited by the World Anti-Doping Agency (WADA) have the right to test athletes. There are now 33 such laboratories in the world, and in Russia there is only one - the Federal State Unitary Enterprise Anti-Doping Center. International sports organizations categorically condemn assisting athletes in the use of prohibited drugs, but there is evidence that in a number of countries there are laboratories that do not operate entirely officially. Of course, they have limited access to new methods for testing prohibited substances. So it’s absolutely true: accredited laboratories can do more and are better equipped, so it’s difficult to deceive them.

However, even these 33 laboratories differ in equipment - it strongly depends on the level of financial support from the state. In addition, it must be taken into account that some laboratories received accreditation only a couple of years ago, while others have existed for thirty years. Therefore, all these laboratories formally comply with WADA requirements, but not all are equally good. In addition, some techniques are mastered by only one or two laboratories in the world. Therefore, doping scandals are still an integral part of modern sports.

If you look at the dynamics, are there more or fewer cases of disqualification of athletes due to doping at each Olympics? What's the trend?

Most likely, we have already passed the maximum. As equipment and chemical analysis techniques improved, more and more cases of violations of the anti-doping code were identified from Olympics to Olympics. I think the apogee was reached in 2004. Now the situation is changing for the better, as well as the consciousness of the athletes, so the organizers of the Olympics this year are hoping for “clean” games.

Prohibited list

This is a list of substances and methods that athletes are not allowed to use. WADA specialists update it every year and publish it on their website www.wada-ama.org. It consists of three sections: substances and methods that are prohibited in sports at all times (both during and outside of competition); substances prohibited only in competitions; and finally, alcohol with beta blockers, which cannot be consumed in some sports during competition.

As a separate point, the World Anti-Doping Agency draws attention to the use of dietary supplements, which may be of poor quality and contain prohibited substances.

The first section contains five classes of drugs and three methods. The first class is anabolic steroids, which includes anabolic steroids and other anabolic substances. These substances accelerate all processes in the body, stimulate tissue renewal, their nutrition and allow you to quickly build muscle mass. Everything is clear about androgenic steroids (male and female sex hormones) - even high school students who come to build muscles for the first time are told about them. But non-steroidal anabolics are a much more subtle substance. These can be blockers and modulators of individual receptors (for example, the drug clenbuterol, which is used to treat bronchial asthma, at the same time it is a powerful fat burner and anabolic) and harmless riboxin, methyluracil and potassium orotate (each in its own way and quite harmlessly increases endurance and regenerative abilities of the body).

The second class is peptide hormones. Within this class there are several groups, including growth hormones, insulins, erythropoietins and other substances that increase muscle mass and reduce fat, increase glucose levels, immunity, endurance and even reduce the number of injuries.

The next large class is beta2-agonists, a wide range of drugs that are used in medicine for diseases of the cardiovascular system and asthma. In healthy people, these substances temporarily increase resistance to physical activity, since they dilate the bronchi and help open the “second wind”.

The next class is hormones and metabolic modulators, substances with antiestrogenic activity. The latter includes the well-known anti-cancer drug tamoxifen (and others like it), which is prescribed as the gold standard for breast cancer in women. In sports, it is combined with anabolic steroids, since an excess of the latter is converted into the female sex hormone estrogen and can “feminize” athletes (tamoxifen competes for estrogen receptors and prevents it from acting). With metabolic modulators, and there are extremely many of them, everything is clear: cell nutrition, metabolism acceleration, endurance, and so on.

Plus, of course, diuretics and other masking agents that allow you to reduce body weight and quickly remove excess chemicals from the body are prohibited. Also on the WADA list are three methods: procedures that activate the transfer of oxygen in the blood; chemical and physical manipulation of blood (including harmless intravenous infusions of saline); and gene doping, including manipulation of normal and genetically modified cells.

At competitions, you cannot use substances of all categories from the first section, as well as stimulants (including nasal drops containing ephedrine), drugs, cannabinoids (marijuana, hashish) and glucocorticosteroids (reduce inflammation, relieve pain).
However, athletes also get sick. Therefore, if you submit an application for a specific medicine in advance, justifying the need according to all the rules of science, you will be able to obtain permission to take it.

Sanctions for anti-doping rule violations range from a warning to a lifetime ban. If a positive test comes during the competition, the results are canceled and the athlete is deprived of medals and prizes. All results from competitions held after the sample was taken may also be disqualified.

Read on Zozhnik:

WADA has the right to review issued permits. TUEs can also be issued retroactively: if an athlete needs emergency care due to a sharp deterioration in health, doctors can use a drug prohibited by the Anti-Doping Code, after which the athlete will be required to obtain permission for it.

Who exactly gets a TUE?

Lists of athletes who have received TUE are not officially published - this is a medical secret that is not subject to disclosure; WADA provides information only on the number of therapeutic exceptions issued (see infographics for this material). Information is also available on drugs that have been approved for use by athletes with therapeutic exceptions.

Since September 2016, the hacker group Fancy Bears began posting documents stolen from the WADA server, which contain the names of athletes who received TUE at different times. Among them are world sports superstars, the Williams sisters, Rafael Nadal (tennis), Ryan Lochte, Mireya Belmonte Garcia (swimming), Fabian Cancellara (cycling), Simone Biles (gymnastics) and others. Letters from WADA officials published in October 2016 by Fancy Bears name more than 200 top US athletes (about half of them in cycling). In February 2017, the doctor of the Norwegian ski team, Petter Ohlberg, mentioned in an interview with the Norwegian newspaper VG Sporten that “50-70% of team members are diagnosed with asthma and take drugs from the prohibited list.” Fancy Bears has published correspondence from WADA, which mentions the names of Norwegian skiers with TUE.

The question of the need to publish information about which athletes received a TUE has been raised more than once. Belarusian biathlete Daria Domracheva believes that the disclosure of this information is a violation of the human right to protect information about private life, but it will not help in the fight against doping. Russian skier Nikita Kryukov said in an interview with the Soviet Sport newspaper that he asked IOC President Thomas Bach when therapeutic exemptions would be lifted, but he replied that it would be difficult to do so. In his open letter in December 2017, Kryukov equated TUE with doping. “If you are sick, then get treatment! If you took a drug that is prohibited, then wait a month, six months, a year until it wears off so that it doesn’t leave a mark on the chart, and then come back. You don’t run competitions in a cast or take off the cast in a week if the doctor told you to walk for six months,” he wrote in an official statement on his website.

How often do Russian athletes get TUE?

In 2017, the Russian Anti-Doping Agency (RUSADA) issued 22 TUEs, and in 2016, the year of the Summer Olympics in Rio de Janeiro, 15. National agencies of other leading sports countries took advantage of this opportunity much more actively. Athletes from the USA, France and Italy received the largest number of therapeutic exemptions (see infographic).

In 2016, 2,175 TUEs were issued worldwide, WADA told RBC. More than a quarter of them (28%) occur in just two countries - the USA and France. The agency associates a significant increase in the number of permits issued in 2015-2016 with the tightening since 2016 of the requirements for entering such information into the ADAMS database (contains information about all movements of athletes and the results of their doping tests, as well as TUEs issued to them).

“Athletes are not receiving more therapeutic exemptions from year to year, but we are seeing more exemptions being issued worldwide due to better compliance,” WADA spokesperson Maggie Durand told RBC.

Why Russian athletes rarely receive TUE

Russian athletes are less likely than their colleagues to apply for a TUE. According to sports doctors, this is due to the weakness of administrators who provide services to clubs and teams, and poor awareness of the athletes themselves about this possibility. The former head of RUSADA, Ramil Khabriev, in an interview with the Sport Express newspaper, suggested that the reason for the small number of applications from Russian athletes may be difficulties in preparing documents. In her book “The Magic of Victory,” Olympic gymnastics champion Svetlana Khorkina said that she learned about the existence of the practice of therapeutic exclusion only from materials published by the hacker group Fancy Bears in 2016.

RUSADA General Director Yuri Ganus, in response to a request from RBC, noted that the reason for significant differences between the number of TUEs issued in Russia and in other countries may be the approaches used in different healthcare systems. For example, athletes with diagnosed asthma (the most common disease for the treatment of which representatives of ski disciplines receive TUE) in Russia are most often eliminated at the stage of children's sections, noted sports doctor, Professor Nikolai Durmanov.

There is evidence that Russian athletes, even when sick, often did without medications included in the prohibited list. For example, at the World Championships in 2010, swimmer Ksenia Popova had an asthma attack during a 25 km swim, and after finishing she lost consciousness. Popova did not use potent drugs and did not obtain permission for them. The diagnosis of asthma was also confirmed for biathlete Alexei Volkov, who won gold in the 4x7.5 km relay at the Sochi Olympics . At two years old, he was diagnosed accordingly, and Volkov was given permission to take medications only two years after the start of his international sports career. Volkov noted that before receiving TUE he did without drug therapy, since exacerbations of the disease occurred in late spring, when the ski season was already ending .

What medications are most often requested by athletes?

American athletes most often issue TUEs for the use of drugs of the group of central nervous system stimulants (138 permits were issued by USADA and sports federations in 2016), Russians and Italians, as a rule, request permission to use glucocorticosteroids - (39 requests to RUSADA and 238 requests to NADO Italia in 2016, the agencies of these countries do not disclose information on the number of approvals issued by type of drug). In France, athletes requested the most TUEs for diseases of the endocrine and cardiovascular systems (a total of 118 approvals for the two specified reasons). In 2016, French athletes received 42 permits to use various glucocorticosteroids.

“This is a group of drugs that are used as widely as antibiotics: for rheumatism, rheumatoid arthritis, bronchial asthma, autoimmune diseases, thyroid diseases. Glucocorticosteroids are also used for all connective tissue diseases,” sports doctor Ilya Melekhin told RBC. In his opinion, if steroids are allowed as a therapeutic exception, they do not greatly affect athletic performance. Doctor Yuri Vasilkov points out that steroids, in addition to respiratory diseases, are used for minor injuries, bruises and sprains. “When they were not prohibited, we were fluent in this technique, administered the drugs where needed, and the recovery period was literally cut in half. Glucocorticosteroids have been widely used in contact sports, particularly football. When we were banned, we began to use medicinal ointments and physical rehabilitation. The time frame [for recovery] is shifting a little, but why should we get caught,” the former chief doctor of the Russian national football team explained to RBC.

The diagnosis often cited by foreign athletes for TUE is attention deficit hyperactivity disorder (ADHD). To treat it, athletes are seeking permission to take stimulants, specifically methylphenidate (commonly known under the brand name Ritalin).

In the United States, in 2016, 138 permits were issued for the use of various stimulants (the American Anti-Doping Agency does not disclose exactly which permits and how many permits were requested). It was methylphenidate that American gymnast Simone Biles, who won four gold and one bronze medal at the 2016 Olympic Games, took; information about the therapeutic exemption given to her was in documents leaked by the hacker group Fancy Bears. After the publication of the data, Biles stated that she was taking the drug with the permission of the Anti-Doping Agency, since she was diagnosed with ADHD as a child.

In Russia, methylphenidate and its derivatives are withdrawn from the circulation of medicines and are considered a narcotic. The diagnosis of ADHD raises doubts among doctors; it cannot be checked instrumentally. According to Alexander Fedorovich, a researcher at the Center for Preventive Psychiatry, the diagnosis of attention deficit hyperactivity disorder is not used in adult psychiatric practice in Russia. “This is a childhood diagnosis, at least in Russia. If such syndromes are observed in an adult, we diagnose “organic damage to the central nervous system” or something else,” he told RBC. However, the criteria for diagnosing “disorder of activity and attention” are present in both the International Classification of Diseases and the American statistical classification of mental disorders DSM-V.

In 2016, RUSADA received only two requests for stimulants and antidepressants; it is unknown whether they were satisfied.

Are there “occupational diseases” of athletes?

The most common disease among professional athletes is asthma, which is typical for representatives of cyclic sports. Research by the American Olympic Committee has shown that it is very common among cyclists (45% of the elite athletes in the study) and skiers (60% of all skiers in the study).

A member of the WADA Medical Research Committee, Professor Ken Fitch, found that athletes with asthma were more likely to win medals at the Olympics in 2000-2010 than athletes who were not diagnosed with this disease: the percentage of asthmatics among all Olympic participants traditionally ranges from 4-7%, and the percentage of winners diagnosed with asthma reached 15.6% of all gold medalists at the 2002 Olympics in Salt Lake City.

Is it possible to fake a sickness certificate to obtain a TUE?

Former doctor of the Russian national football team and Spartak Moscow, Yuri Vasilkov, in a conversation with RBC, expressed the opinion that it is impossible to obtain a fictitious certificate to obtain a TUE. “Everything is checked there [at WADA], such jokes don’t work there,” he said. National Anti-Doping Agencies and International Sports Federations may submit a request to WADA to review decisions regarding therapeutic exemptions issued to athletes of a competing team. In this case, a WADA specialist will need to confirm that all criteria for issuing an exception are met.

A 2013 study of Danish athletes (studying 645 people in 40 sports, of whom 19% had ever received a TUE) found that 51% believed that their competitors may have been inappropriately given therapeutic exemptions for non-medical reasons. diseases, but to improve the result. 4% of respondents called this “normal practice.” Moreover, athletes who had already received a TUE were more likely than their colleagues without such experience to say that unscrupulous competitors could bypass the system of control over the issuance of therapeutic exceptions.

Does the TUE dose of the drug help improve athletic performance?

The standard to guide physicians when deciding whether to issue a therapeutic exemption emphasizes that the drug should not have a significant effect on the outcome. However, in practice, determining the degree of influence is not always possible, experts say.

Sports traumatologist, Candidate of Sciences Artem Katulin believes that medical indications for the use of substances prohibited by WADA put athletes in a “more advantageous position.” In his opinion, there is a clear line between when a prescribed drug only treats and when it begins to have a significant impact on athletic performance, and this line is determined individually for each person.

Of the drugs for which athletes most often request a TUE, stimulants (dispensed to athletes diagnosed with ADHD or narcolepsy) may have the most obvious effect on performance. Corticosteroids, when used systematically, can also have a stimulating effect, points out Professor Ken Fitch from the University of Western Australia. Martine Duclos, a professor at the Center for Sports Medicine and Functional Research at the University Hospital in Clermont-Ferrand, also noted the stimulating effect of glucocorticosteroids on the body of athletes.

The dosage of drugs prohibited by WADA is determined by the doctor prescribing the treatment. There are no clear restrictions on dosage in the rules for obtaining TUE, except for the principle that the prescribed dose is “lowly likely to lead to improved athletic performance.”